Provider Demographics
NPI:1265795025
Name:EVANS, TANIA (CRADC)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:CRADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N SHAMROCK ST
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-0016
Mailing Address - Country:US
Mailing Address - Phone:618-258-0021
Mailing Address - Fax:
Practice Address - Street 1:211 N SHAMROCK ST
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-0016
Practice Address - Country:US
Practice Address - Phone:618-258-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25625101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)